Family critical of care home as choking inquest begins

An inquest has heard how a man with Down's Syndrome died after choking on a conker that was part of a sensory activity for another resident at his home .

Marcus Hanlin, 57, was left unsupervised at the time despite his mother saying he was on a support plan that required him to be supervised at all times when around food due to swallowing issues.

At the time of his death in 2022, he was a resident at Cheddar Grove Nursing Home, a specialist nursing home for people with learning disabilities in Bristol.

His mother said: "The loss of his life in this manner is beyond bearing."

The charity Inquest, which looks into deaths involving state institutions, says Mr Hanlin's death is one of at least 18 involving vulnerable people with learning disabilities who died by choking or following a swallowing incident in a care setting since 2015.

Mr Hanlin had particular needs around eating and drinking, which were frequently assessed by the Speech and Language Therapy (SaLT) services.

He was subject to an eating and drinking support plan and required supervision at all times at the home in the Bedminster Down area of the city when around food due to swallowing issues and an identified risk of choking.

On 28 September 2022, Mr Hanlin was left unsupervised with a bowl of brightly-dyed rice, in which conkers were hidden, as part of a sensory activity for another resident at the home.

The inquest, held at Avon Coroner's Court at Flax Bourton, was told that he swallowed two conkers and some dyed rice.

He became unwell and was hospitalised at Bristol Royal Infirmary, where he died five days later.

The cause of death was given as aspiration pneumonia and pharyngeal and oesophageal obstruction due to ingested conker and aspiration of rice into the lungs.

The presence of conkers was only discovered after Mr Hanlin’s death.

His mother Anna Rose broke down in tears as she described his death to the inquest, saying: "Marcus opened his eyes and seemed to look at us and then he was gone."

She was highly critical of Cheddar Grove over their lack of supervision, particularly when he swallowed the conkers, adding: "At no time did any one from Cheddar Grove or hospital say Marcus had swallowed conkers.

"We understand Marcus had swallowed dried rice and two conkers - this was an incredible shock.

"We wondered if this had been discovered through additional tests and that something so predictable could have been allowed to happen.

"The loss of his life in this manner are beyond bearing. We hope others can be saved the same suffering and the same family heartache."

Mrs Rose also criticised the Bristol Royal Infirmary for only providing a specialist disability learning nurse on a few occasions.

She added: "The difference the learning disabilities nurse made in her brief visit was enormous. If one had been available this would have likely have made a big difference to his stay."